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Balancing Ethical Issues, Knowledge and Experience in

Leadership in Health Care Institutions.

Insights and Reflections from a Christian Physician

V. Gemou-Engesaeth MD. PhD., University of Oslo and University of Athens

Master Thesis

The experienced based master studies in health administration and leadership

Class No XIX

Institute for Health Management and Health Economics

Faculty of Medicine

University of Oslo

January 2014

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Balancing Ethical Issues, Knowledge and Experience in Leadership in Health Care Institutions.

Insights and Reflections from a Christian Physician V. Gemou-Engesaeth MD. PhD., University of Oslo, MD. PhD., University of Athens

(Picture 1: Photo by V. Gemou-Engesaeth, 2013, Athens)

Left: Hippocrates and Dexippos. Right Medicine and Theology. Administrative Building of University of Athens, School of

Medicine, in the central meeting room, Goudi, Athens.

Master Thesis

The experienced based master studies in health administration and leadership

Class No XIX

Institute for Health Management and Health Economics

Faculty of Medicine, University of Oslo

January 2014

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To my special teachers: To the one I wish and pray to live very long, Ole T. Berg and

To the other I miss, Sverre Halvorsen The teacher: by KOSTIS PALAMAS Tumble again, teacher, souls! And that in still left in your life, Don 't deny! Sacrifice it to the end of your breath! Build the palace, wise teacher! And even if some force in your body still remains, Do not get tired. Your soul is made of steal. Now put foundations deeper, The war must not tear them down. Dig deep. What if many have forgotten you? They will remember once they too The weight you hold on your shoulders like Atlas, Patience builds, a wise, society Palace! Oh. My wonderful wise teachers! Who will teach my children! How wonderful I feel to step on your shoulders.

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Contents

The teacher: by KOSTIS PALAMAS

Acknowledgments

Abstract

Chapter One: Introduction Topics and Research questions 1. Background and definitions 2. Main topics and research questions 3. The changing role of medical ethics 4. Some examples of politics and value conflicts that prove the call to Hippocratic

values

Chapter Two: Methods in a historical view Methods Chapter Three: The beginning. Hippocratic Medical Ethics

1. The introduction and continuation of medical ethics 2. Aristoteles´ virtue and Hippocratic Ethics 3. Ethics in theory is also a question of personal character (Greek approach)

Chapter Four: The Hellenization of Hippocratic Medical Ethics

1. Hippocratic Medical Ethics in Hellenistic times Chapter Five: The Christianization of Greek Medical Ethics

1. Christian Ethics 2. Hippocratic Medical Ethics from early Christian times to pre-modern times

Chapter Six: Modern Medical Ethics 1. Deontological medical ethics according to Kant 2. Utilitarianism

Chapter Seven: The continued relevance of Hippocratic Medical Ethics and Christian Ethics Chapter eight: Renewing the relevance of Hippocratic Medical Ethics and Christian Ethics - a political approach Summary and Concluding remarks

Poem of Sappho

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”To my Parents I owe my life, but to my Teachers I owe my good life” Alexander the Great

I become old and I learn endlessly a lot

Solon the Athenian

This I know that I know nothing Socrates

Acknowledgments

Education goes through life. He who believes he has finished his education, he is not ready but finished. (Aristotle, Katharsis).

These studies and exams have for the most part been additional to my routine clinical, research, teaching work in the various departments and hospitals in which I have performed my duties. In parallel to this, my ordinary work, I have done, charity work on different boards within the medical profession. Thus, there is a large number of people I want to thank. They include colleagues and friends. They also include people whom I have met participating as substitute member of the Board of the Christian Council of Norway (CCN) in the capacity of being the Spiritual Leader/Legal representative and administrative Director for the Greek Orthodox Parish, President for the Greek Orthodox Community in Norway and main representative of the three orthodox communities that are members of the Council. The collaboration with them allowed me to develop new life long friendships and to see the world from new perspectives. They are too many to be listed by names. But they will retain a place in my heart and soul.The collaboration with them allowed me to develop new life long friendship and at the same time to achieve better knowledge and qualities that made me to see the world in different perspectives. - I would like first to express my sincere and wholehearted gratitude to Professor Ole. Berg , who was my teacher in health administration and my main tutor when I was writing this thesis. My decision to take the Executive Master’s degree in Health ddministration was a choice that made a difference in my career. Ole Berg, together with others of his colleagues at The Department of Health Management and Health Economics inspired me to go deeper into the relationship between values and the management of medical care. - My thanks also go to my other very special teacher, a leading authority in pediatrics, the late Professor Emeritus/ dr. med Sverre Halvorsen, at the Dept. of Pediatrics, Ulleval University Hospital. He has supported me like a father since I first arrived in his department almost 30 years ago and until he passed away in August of 2012.

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- I am obliged and grateful to Professor in Systematic Theology Dr. Theol. sr. Else-Britt Nilsen, MF Norwegian School of Theology, for stepping in on a very short notice to help in her capacity as a co-supervisor after this thesis had come almost to its end.

- My wholehearted thanks also go to Mr. Mr. Jeronymos B´ Archibishop of Athens and the whole of Greece for all collaboration, support, help, kindness, and everything he has been for me. In addition to being a good, kind “father” and an openminded friend long before he was appointded Archbishop, he continues to be a trusted friend. He proved also was a good Ambassador for Greece during the study tour of my Oslo class to Greece, in Comparative Health Politics. I am furthermore greatful to him for presenting to me the theologian, dr. father Maximos Papagiannis and theologian/psychiatrist Professor dr. father Adamantios Avgoustidis, Theology School of Athens University, who read through and gave fruitful comments to this thesis. I thank them all from the bottom of my heart.

- Then I would like to thank every other teacher of the Oslo department, especially the previous Director Professor MD. PhD Grete S. Botten, now retired, and her successor, Professor Terje P. Hagen and many other people in the department.

- It would be an omission not to mention Mrs. Margery Sitkin. She helped me in all practical ways, and always with a warm smile.

- I have also to thank the successor of Margery for all practical help. Sorry this writing took so long Deborah Ann Arnfinsen, it wasn’t deliberate. You know the most important reasons.

- I would like to thank several fathers of the Greek Orthodoks Church whom I met mostly in our Greek Orthodocs Community in Norway but also others. We have become lifelong friends. I have worked with them for almost 30 years, and have learnt and experienced so much that has no doubt contributed significantly to the content of this thesis. I am equally grateful to all of them; therefore I will not mention anyone in particular. - My sincere thanks go also to those of other communities within the Byzantine rite, which I was representing in the Norwegian Christian Council, especially I thank father Kliment for his kind help and support in several occasions. I really enjoyed the help and the mutual respect, cooperation and support of everybody with whom I had to cooperate; My special thanks go to the General Secretary Rev. Ørnulf Steen of the Norwegian Christian Council and his successor Rev. Knut Refstal, and their colleagues, for being all like sisters and brothers in Christ in an ecumenical existence through all these years.We truly loved each other; we became good friends and I pray that our friendship will last. - My sincere thanks go also to my dear friends and co-workers of The Catholic – Orthodox Forum for all their kind support through many years. They mean a lot to me.

- I need to further thank all my dear friends and very special colleagues for encouraging me to pursue this thesis, particularly the senior consultants pediatricians, drs. med. Torild Skrivarhaug and Marit Hellebostad, he Head Nurse Gunvor Lada, now retired, and

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Elisabeth Johansson in the Pediatric Department, Ulleval University Hospital, where I used to work. They meant and still mean so much to me.

- I would also like to thank my dear colleagues and friends, Chairmen and Professors MD, George Chrousos and Georgia Chrousos, and Assistant Professor Athanasios Kaditis, who took the time to read and comment upon a draft of this thesis. I would also like to thank Georgia Chrousos for constantly encouraging me to pursue this thesis. I also thank Head Nurse Panagiota Sotiropoulou and my clinical and research fellow pediatricians Ioanna Vasilopoulou and Niki Laliotou and our most capable secretaries Elli Papadimitriou and Maria Malouhou in the First Pediatric Dept. of Athens University for special moral support. I owe them all a trip to the Sognefjord!

- I would like to thank my patients, their parents and my students for their trust, love and support. When I teach students, doctors, or nurses, patients or give lecture elsewhere I tell them in my ways how important it is to be kind to others, to love oneanother, because this is the right thing to do for us as human beings and especially as doctors. If we do so God will reward us. I see this more clearly now than ever. I never regret that I left a secure Norwegian life to show Norwegian solidarity to my Greek people.

- Finally, I would like to thank my family and especially my husband, Leif Engesaeth, my son, Athanasios Edvard, and my daughter, Maria Athena Beatrice, for help, advice, inspiration, for all the moral and practical support they have given me over the years, and for permitting me, during the work with this thesis, to be absent at several family and social events. - Finally I will thank God for everything I am and I have in my life and especially that he brought me back to my beloved, now severly ill, old mother!

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Balancing Ethical Issues, Knowledge and Experience in Leadership in Health Care

Institutions.

-Insights and Reflections from a Christian Physician-

V. Gemou-Engesæth MD. PhD., University of Oslo and University of Athens

Abstract

Purpose: The purpose of this thesis is to critically examine the importance of applying a

combination of Hippocratic and Christian ethics in modern medicine.

Background: The ethical values should be an essential part of health care leadership and

health care organizations. Since antiquity, Hippocratic medicine´s overarching concern

was to put the patient first. This is apparently also the aim of medicine as it is practiced

today. But is this true? What is the actual reality? Hippocratic ethics, as it is reflected in

the Oath and Christian ethics, have the promotion of health as its main objective.

What values should characterize the relationship between physician and patient and

among physicians themselves? In the Hippocratic tradition, the physicians of ancient

Greece were members of a religious cult as much as they were physicians. This is very

important. What comes from insight is also divine. Physicians deal with man´s health. A

man is a person with body, mind and soul. In the Holy Bible, sanctity is identified with

God and not with man or holy things, like in ancient Hellenism. The Fathers of the

Church identified sanctity with the “person”, the ”prosopon”. In the Orthodox Christian

tradition: The prosopon is created in the image of God.

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In modern times, modern ethics, is dictated by man. It is a function either of his/her

“pure” thinking or his/her “secular” evaluation of the anticipated consequences of

different courses of action. In the first case we talk about an ethics of obligations or a

deontology, in the second case about utilitarian ethics. Deontology may seem to reflect a

“denaturation” of Christian ethics. Utilitarianism is a more directly secular ethics. It takes

as its point of departure man’s worldly interests. These two ethics, and particularly the

latter, increasingly dominate modern ethical discourses, also the ones that take place

within medicine. This thesis tries to explain why the ethics of the Christian and

Hippocratic traditions have come on the defensive in modern society, but also discusses

the potential that these traditions continue to represent themselves.

Methods: This thesis explores briefly some of the literature on medical ethics, primarily

from an historical perspective. The development is traced from the Hippocratic to the

Christian times and finally to the modern, secular era. It is shown how this development

has ended up in a deep crisis. At stake is the status of man as “prosopon”, as “anthropos”.

Findings: Modern health care is characterized by its dependence upon secular science

and technology. This dependence has made it possible to treat physical and mental illness

in a way that is unprecedented. The image of man though, which this science is based on,

is also relativizing the view of man, as something sacrosanct and holistic, making it

increasingly difficult for physicians to know how to proceed ethically. As modern

medicine is increasingly becoming an industrial empire, tightly managed, it is also

becoming more and more difficult for the individual physician to exercise his or her

personal ethical judgment in his or her encounters with patients. His or her practice is

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increasingly being dictated and controlled. This system of governance from above also

undermines physicians’ possibilities of organizing their work as they think, both as it

regards their professional competence and their ethical concerns, thus strengthening their

feeling of being alienated.

Conclusion: The Hippocratic “enterprise” was inspired by humanistic ideals and an

undeviating dedication to the patient. It was also founded on the belief that

professionalism and ethical consciousness, first of all, had to be safeguarded, through

collegial cooperation – i.e. through the brotherhood of physicians. These ideals,

complemented with Christian ideals and adapted to our times, should be inspiring

physicians today, and should provide premises for the organization and management of

health care institutions.

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Chapter One: Introduction Topics and Research questions

1. Background and definitions

Physicians’ concern with ethics is as old as the profession itself. In the West, thus, it

dates back to the fifth and fourth centuries before Christ, to the emergence of the

Hippocratic “school” at the Greek island of Kos. This school’s ethics is expressed

primarily in the Hippocratic Oath. The Oath is part of the Corpus Hippocraticum, the

collection of the extant works coming out of the school at Kos. The ideas informing the

Oath have continued to shape the ethical attitudes of physicians ever since, though

medical behavior has gradually moved away from the deeper implications of the Oath. It

is, however, interesting that the Norwegian Medical Association´ s Ethical Rules for

Physicians of 1989 expresses ideas virtually identical to those expressed in the

Hippocratic Oath (Engelskjøn 1996, Kunstadter, 1980, Marketos, 2000).

Ethics derives from the Greek word ethos (έθος), which means manner, habit, custom,

tradition, and as a discipline it is the study of human life and its values. The term

“medical ethics” refers primarily to ethical rules which regulate the way in which doctors

and other medical personnel relate to patients (Kunstadter, 1980)

Hippocrates, the father of medicine and the most important among the Asclepiads, gave

solid advice to doctors and to other people caring for the ill. This advice which guided by

ethical principles and values (Marketos, 2000, 2004, Kunstadter, 1980).

According to Hippocrates, medicine should also be based on philosophy. Plato said (in

Phaedrus): “Without philosophy medicine it is no longer an art, but a low vulgar craft,

because it is philosophy that promotes grandeur of conception and completeness in

execution” (Marketos, 2000). Hence, medicine not based on philosophy, does not inspire

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confidence among patients their relatives, and their surroundings more generally,

Hippocrates contended. Thus, a good doctor should also be a good philosopher. This is

particularly the case for the ethical side of the doctors´ practice.

The Oath of Hippocrates begins as follows:

“I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods

and goddesses (see appendix 1).

The physicians of the ancient Greece were members of a religious body or cultic

community as much as they were physicians. Thus their obligation toward their patients

was sacred.

Aristotle pointed out that the traits and norms, which are the basis for right actions must

be decided in accordance with the practice they are to be applied to. A good soldier has

different qualities than a good philosopher. The Hippocratic tradition, as we have said,

demands, that a good physician should also be a good philosopher. The ethical and

philosophical issues of Hippocratic medicine reveal that creativity in physical philosophy

and medical art were more closely associated than medical historians have realized.

Hippocrates was respected not only because he was a great physician and famous medical

teacher, but also because he was an inspired philosopher and outstanding thinker in the

history of medicine. Ancient Greek medicine was based on coexistence, on the

”marriage”, of Asclepian (religious) and Hippocratic (rational) medicine (Katsambas,

Marketos, 2007). This is an extremely important point to keep in mind in order to

understand the contrast between the ancient Greek community of physisians and the

modern aggregate-like association of physicians.

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The Hippocratic Corpus was known in ancient Rome. The Oath´s compatibility with

Christianity probably secured its survival as Christianity´s power and influence grew in

the Middle Ages. A Christian version of the Oath dates back to the 12th or 13th century

AD (Engelskjøn, 1996).

Christian Ethics refers to what is good and evil, right and wrong and has its roots in the

Old Testament. The principles of the Old Testament´s ethics include the Decalogue (see

Appendix II). The Decalogue, or the Ten Commandments, gave the people of Israel its

standards of right and wrong. These standards have also been central to Christianity. But

through the New Testament these standards have also been further developed, not least

through the example represented by the teaching and, not least, behaviour of Jesus Christ.

Christ said: 'Love the Lord your God with all your heart and with all your soul and with

all your mind.' And 'Love your neighbor as yourself' (Matthew 22:36-40).

Medical ethics has its basis in the Hippocratic teachings. During the Christian era, i.e.

primarily the Middle Ages, this system of ethics was to some extent influenced by

Christianity, though it remained primarily Hippocratic.

Without doubt, early Christian ethics were influenced by Stoic Greek philosophy. It is

important to remember that the profound nature of Christian ethics leads us to think of

something ideologically dogmatic or foreign to the daily reality of human life. But if we

study the doctrinal life of the Church, we will notice that the life of the Church has never

suggested anything foreign to human nature or inappropriately artificial, because it is

nothing other than Jesus Christ, the Son of God incarnated that provides the full

revelation within the continuity of His soteriological efficiency in history, through the

Holy Spirit (Ioan, 1993, St. J. Damascene). Christian ethics teaches us the attitude basic

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to true Christian humanism showing that all is beautiful within the world and that

therefore nothing is foreign or incompatible with Christianity (Florea, 2008). This type of

ethics is based upon the theology of the Gospels of Luke and John, and with ethical ideas

from the works of a number of ecclesiastical personalities. The humanistic characteristic

of Christian ethics, thus, has at its center the real historical man and not the abstract man

of the philosophies of man.

Ethics designates the way we ought to live. An objective standard assigning value to

individual character and behavior, representing the relationship among the individual and

his/her objective duty (Yannaras, 2002). Christian ethics may be a guide to the care and

responsibility of man.

Modern Christian ethics has to some extent changed by the influence of various

theological movements and philosophies, though, as we will see and discuss later.

The hippocratic writings imply the view that in order to be a good physician one must

first be a good human being. The coexistence of religion and rational medicine in

Hippocratic medicine is therefore no mere coincidence. Rational Hippocratic medicine

had a parallel in the religiously inspired Asclepian medicine. In modern medicine this

unity of a sacred ethics and a rational science has been broken.

Modern science proceeds as if God, or gods, or any kind of transcendental has not being

existed. Thus its ethics becomes subordinated to science; indeed it becomes its

handmaiden – that is to say, it becomes dependent on what the science of medicine makes

possible and on the kind of image of man it creates. Given medicine’s fundamental

assumptions, that no trancendent force exists, this image is bound to become

materialistic.

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In pre-modern times, man was, in principle at least, seen as a whole. Now he is

increasingly being torn apart, or looked upon as an aggregate entity. The patient is looked

upon a machine, and more and more made into a machine, and medical care is being

turned into a ”soulless” production process.

It is not surprising that several studies show that at the beginning of their studies today,

medical students in Western universities have an idealistic attitude to the practice of

medicine (Nyborg 1996, Sullivan and Chumbley 2010). During their years in medical

school, students´ attitude become, more cynical. They learn to prioritize what is

necessary in order to succeed to pass their examinations, as they are confronted with a

great amount of requirements. Students learn to study diseases throught the books and

lectures and not to help sick patients at the bedside. In sum, they learn to adopt a mostly

instrumental approach to what used to be their calling. Hippocrates taught us, that

“Medicine cannot exist without observing the patient”. The three interacting elements

upon which Hippocrates based his medical doctrine are:

- The patient who is a psychosomatic entity.

- The disease that is governed by rules,

- Physician (the healer) who is nature´s helper and servant of medical art

(Katsambas and Marketos, 2007).

Medicine can do marvelous things today. At the same time it is depersonalizing the

patient. These changes, seen from an ethical perspective, have resulted in not seeing the

patient as a special individual being, but only as a case, or a category, of this or that sort

(Marketos, 2004). This depersonalizing trend is strengthened as medical care, broken

down into procedures, which are also seen from an economic perspective (Florea, 2008).

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The principle of love and moral life is turned away from inspirations as perfection,

spirituality, and communion with God. Power may lure the physician, like any other

individual, into the world of “filautia” or “selfishness”, and thus sometimes also into the

moral catastrophy of the individual physician, a catastrofee that may contribute to a wider

societal moral catastrophe, characterized by a materialistic view of man and life, spiritual

indifference, superficiality, and fragmentation of culture. Individual insists on human

reason eliminating God as the center point of moral reference (Florea, 2008). In other

words, this may lead society to a crisis and a political corruptness (Transparency

International, Kjetil Mæland)

2. Main topics and research questions

There is an impression that, in the society´s eyes, the medicalchapt profession faces a

crisis much different from what physician experienced before the establishment of the

quite recent health care system. But why did this happen? What are the reasons for this?

Do Ethics play a role here? Does this have to do with the individualistic concept, of the

physicians of today´s medicine, the spiritual indifference, and isolation? If the answer is

yes, how can this be improved? We will try to examine these questions in a historical

perspective and we will try to answer them, though it will not be an easy task. One may

think that those questions would sound controversial to some extent. Moreover, one may

think, that these should apply to any group of the society and not only to doctors. It is

important to repeat that the reason of writing this thesis is to make reflections upon

doctors and today´s Medicine in a very brief way. Thus, this attempt could not be in any

way considered comprehensive. The intentions are positively meant, and the intention is

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to express profound thoughts, no matter if one would agree or not. The main purpose is to

convince as many as possible to reflect on the subject too. We will base our efforts on

looking into the roles of medical profession and its objectives. Therefore it is important to

see briefly what these roles are.

In 1986, Larsen et al., stated that the role of physicians might be divided in three parts

(Larsen, 1996). The first part is to serve the ill or to prevent illness. This role is based on

his or her medical skills and competence to save one´s life, when one is in need for

survival, and should be given adequate service. In this respect the patient – doctor

relationship is most important. Hippocrates had at his disposal only the patient´s history

and the physical examination. He observed patient and diseases with the eye of a

naturalist and established rules for the physician to use at any case and at any time.

The second part is the one of the caring supporter, when the physician gives the comfort

a patient needs during the hardship of the disease. Hippocrates had a profound

understanding of human suffering, had knowledge of the limitations of human life, and

emphasized that the place of the physician is at bedside of his patient and that “to restore

every sick to complete health is impossible”. He supported that “sometimes it is a good

drug to use nothing”, and treatment included fresh air, proper nutrition, moderate

exercise, healing plants, hot baths, surgical procedures, etc. The third part is the role of

the gate - keeper. The physician has the authority to give access to public support, and

public money. All these roles that a physician performs should be based on ideological

principles, strongly related to ethical values too.

The professional objectives, however, should be supplemented with different practical

responsibilities for the doctors to serve their roles according to Larsen et al., 1986.

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To serve the ill, doctors need a continuing education within the different branches of

medicine. In addition to this, doctors have to understand and serve the science. An

interest in biomedical research contributes to scientific progress and will strengthen the

profession.

We believe that, although the recent advances of biotechnology have changed the whole

world of medical science, Hippocratic ethics is still needed in contemporary medicine.

Today´s physician can benefit from the Hippocratic ethical principles and the Hippocratic

valuable clinical concepts, and by having those in mind at everyday learning and in the

performance of medical practice, the contribution to the scientific progress and to

doctors´ medical practice would probably have a more significant effect.

In no other profession do ethical and philosophical issues count much as in the medical

profession. Hippocratic ethical concepts are described in five books, i.e. the Oath, the

Physician, the Law, Medical Decorum, and his famous Aphorisms (Katsambas and

Marketos, 2007). Hippocratic medicine and pre-Socratic philosophy combined the 6th

century BC concepts of the Ionian philosophers of Asia Minor with Pithagoras of Samos

(580-489 BC). According to Hippocrates, human beings are made of a soul and a body,

which contain four body humors or fluids (blood, phlegm, and black and yellow bile).

These elements correspond to the four organs of the body i.e. the heart, the brain, the

liver, and the spleen. The equilibrium, in other words the balance and the harmony;

between the four humors (in Greek eukrasia) are synonymously recognized with health.

In the opposite case when this equilibrium is disturbed (in Greek dyskrasia) we have the

disease.

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First we would like reflecting upon the above-mentioned changes and to look upon the

importance of applying Hippocratic Medical Ethics as taught in ancient Greek times.

Healing in the ancient world of Hippocratic times seem to have taken place within a

context that was religious, which also provides unity of the physicians, i.e. the ancient

Greek community understanding, and sees the patient in a holistic approach. The

avoidance of pagan supernaturalism made Hippocratic medicine congenial to Christians

and led to the acceptance of natural origin of the diseases by most of the early and late

Christian writers.

Second we will look into the effects of the above mentioned with respect to combining

cultural changes with Christian Ethics and Hippocratic Ethics. The questions are whether

medical ethics of Hippocratic tradition are valid still in our times, and whether the

influence of Christian ethics, as these are based at biblical origin, are relevant through the

centuries, up to today´s Medicine. By following briefly the literature we will see shortly

how medical ethics gradually are transformed.

3. The changing role of medical ethics

The “paradigm” of Modernity was based on the egocentrism of “human rights”

(Yannaras, 2002). This historical development of Modernity may play a central role in

the crisis of today´s medical ethics or in the doctor´s role and crisis of the society at large.

Hippocratic values and Christian ethics need to be reconsidered, and applied together in

today´s medical praxis. The roles of the physician as mentioned here above in chapter

one, point 2, and also we will see latter are to a large extent changed in our days, based

on attitudes held by the outside world. The images of the doctor today have been

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culturally determined and dictated into a changed new role. The doctor of today has

accepted his new role to act according to expectations of the modern society, and his

success is depending on how well the physician can live up to these modern changes of

society. According to these historical variations, the professional objectives may be

sorted into a new list with four different consequences for the members of the medical

community (Larsen, 1996), which may be regarded as paraphrases of the statement

included above in terms of the obligations of the physicians (Kunstadter, 1980). The first

role, namely to serve the sick, is a central objective. This must have priority, and it is

morally rooted, as the relationship patient-doctor is the doctor´s most important call. In

1976, professor Peter F. Hjort and his group had the objective to study the function of the

Norwegian health care system, its services to the individual and to the society, its use of

resources, and its quality. From 1978 onwards, a series of reports have been published.

Medicine was put into a framework of economy and sociology that was new and felt as a

threat to old values. The second role to serve the society is the leading star for those who

have established the Norwegian health system. That means the politicians. The third

objective is to serve science. This has to be done in addition to a doctor´s clinical work

and often by sacrificing family and personal economy. The fourth and legitimate

objective it is to serve yourself in order to succeed in personal goals and self-promotion

(Larsen, 1996, Hjort, 2001). But in those perspectives medicine becomes as one of the

several possible pathways to obtain the goals. To the leaders of the medical profession

and Health Services as a whole are a constant challenge and a setup, which demands

codes of ethics and norms to be present in any action for progress. Our actions, especially

as doctors, must be judged in all instances by laws, ethical standards, spiritual maturity,

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justice, and faithfulness to patient’s rights, by avoiding politics that deviate a doctor´s

role away from Hippocratic values. Hippocrates was concerned with the physician’s

duties rather than his “rights. The notion of “right” has been known in the West since the

Middle Ages. However, in the Middle Ages, the rights concerned specific individuals or

specific social classes. The radical innovation of Modernity lies in the fact that it made

rights ”human”, i.e. common for all humans, without discrimination. The protection of

human rights became the symbol of modern western civilization. In Modernity,

“individual rights” protect an individual from the arbitrary exercise of power. But in

Ancient Greece, the power meant all citizens together (the demos) – and the “State”

(Power) belonged to the demos (democracy). In Ancient Greece, any bodily punishment

of harm was unthinkable for a citizen. The ancient Greek paradigm helps us to

understand the attitude of the Orthodox Church, (if we exclude the ideological

“Orthodoxism”) vis-á-vis the “human rights” issue (Yannaras, 2002). The Greek

political model was the historical flesh, which realized and revealed the radical difference

between Church and religion. Being member of the church is a way of communion

between persons, a way of materializing love, i.e. expressing the freedom of existence

from nature. On the contrary, religion is an individual effort towards individual virtues,

individual justifications, and individual salvation. Individual rights in modernity are not

arbitrary. When the tyranny of metaphysics was rejected, the aim of the individual

metaphysical salvation was replaced by the aim of a secularized (legal) protection

(Yannaras, 2002). The commercialization of politics, their submission to the laws of

publicity and the brainwashing of the masses, literally abolished the “representative”,

parliamentary system. Politicians do not represent citizens and their interests but the

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economic capital of the electoral propaganda and the interests of the fund providers

(Yannaras, 2002). The networks of economic and political interests lead to a social

corruption (Corruption is the abuse of entrusted power for private gain), which increases

dramatically through the immorality of the mass media and their functioning (Yannaras,

2002). Therefore Hippocratic values and Christian ethics are needed to be reconsidered

and be applied together. But how can this be achieved? This can be again achieved by

educating politicians or by controlling politics.

4. Some examples of politics and value conflicts that proof the call to Hippocrates

Here we will see shortly some examples from literature in politics and also value

conflicts, which indicate the need to combine the concept of Hippocratic medicine in a

balanced way in our Christian times of modern medicine.

There was inevitably a sense of crisis, but now we can see it and feel that it is present.

Previously, junior physicians experienced relatively limited career development, but they

knew when they would be promoted to chief physician´s posts, conditions would

improve. On the other hand there are more complains than in the past about treatments

given to patients and patient claimed compensations in Norway (Evensen, 1996). There

are also positive signals. The modern criticism is to some extent unjustified; because of

this many times it is based on factors arising from political decisions and consequences.

An increasing economy and cost of the health sector has increased the pressure on the

employees. Health care organizations are in many instances now turned into business

organizations. It is important to focus therefore, on the issue whether moral / ethical

values exist in their daily practice. Conflict may arise in healthcare management as a

23

result of different philosophy amongst professionals relating to how care should be

delivered, because of the biases resulting from value conflict, such as cost vs quality.

However not all value conflicts are either good or bad. Fundamental values represent core

beliefs that are persistent over time and individuals will strive to protect and defend these

beliefs at any cost (Carney, 2006). When conflict involves core values, emotion enters the

arena making resolution more difficult. In that case individuals will be less inclined to

use compromise as a solution. A modern form of ethical conflict is that of clinical vs

organizational conflict, which often collide. The evaluation of healthcare delivery is

governed by cost cutting, and the need for greater efficiency and effectiveness is present

now than ever before. Equity in health care delivery ranked eight in a scale of ten. This

was identified by accessibility; timely care delivery, in addition to equity in the

management of staff. Inclusiveness, objectivity, honesty and transparentness, were the

hallmarks (Carney, 2006). Groups had different beliefs in how patient care is delivered.

Some believed research was more important than healing and vice versa. Values when

discussing interpersonal relationships between health care personnel and the patients

include compassion, concern, tact and sensitivity (Donabedian, 1988, Carney, 2006).

Sowmini and De Vries 2009, in a cross cultural review of the ethical issues in dementia

care in Kerala, India and the Netherlands have shown that institutionalized care was more

common in the Netherlands as well as more costly. Whereas in Kerala patients with

dementia receive home-based care, the situation is quite stressful for the caregivers.

Interestingly, the legal and social care setting of the Netherlands has a strong influence on

physician decision-making concerning end of life issues. The Royal Dutch Medical

Society identifies four kinds of life shortening actions. These actions include withholding

24

treatment, stopping treatment, treatment of symptoms accompanied by shortening of life

and actions that terminate life by administering lethal drugs (Cusveller and Jochemsen,

1996). The striking similarities in the demographic trends of the two regions belie a

remarkable different approach to the end of life. Despite the stronger gravity of dementia

in terms of the quality and number of the patients in Kerala, the issue of euthanasia

remains totally alien there. This is the result of ethical issues related to dementia and

cultural factors, belief and ethics, with its concern for the relational and spiritual

dimensions of human life (Sowmini and De Vries 2009). In secular Netherlands,

euthanasia is seen as a physical matter, a strategy to reduce suffering, neglecting by far

the issue of spirituality, humanism and love. Without doubt, medicine with no

Hippocratic or Christian ethics might becomes a dangerous profession.

It is well known that during the Hippocratic era there was a complete separation between

killing and curing. Therefore, the above examples call us physicians to reconsider the

Hippocratic tradition in which the physician promises to act primarily for the benefit and

not for the harm of patients, to protect their confidences, to refrain from performing

euthanasia and abortion and from having sexual relationships with patients or their

families and to lead a professional life of moral values (Marketos, 2004). Findings from

Sowmini and De Vries, 2009 and from Carney, 2006, indicated the presence of

unrealistic expectations of care delivery among clinicians and it is likely that clinicians

misunderstand the ethical tension between cost efficiency and quality of care. The new

health service culture has yet to be accepted by some professionals. Wyller et al, 2013,

state that everyone agrees with the goals of the Norwegian health care system. But there

is a disagreement on the instruments to apply it. Minister prescribes a steady course.

25

Physicians believe that the current course leads them further and further away from the

goals. Physicians see clear signs of decay in moral and in the health service. A radical

change of course is needed. Therefore, in our days we should consider, that spiritual ideas

and care of the elderly and medical practice in general need to be concordant with

cultural and religious factors. Many argue that the status of the medical profession is

devaluated. Physician’s development has been unsatisfactory. Health sector became an

arena of professional battles. There appeared to be conflict between physicians and the

mass media with regularly publicised stories of dissatisfied patients. Media´s focus was

on physician´s mistakes most of the times. The legal system is considered a threat; and

many studies of physicians´ living standards and working conditions during the end of

the 1980s and the beginning of 1990s and in recent days, have shown a high degree of

dissatisfaction. It is symptomatic that both Health and Prime Ministers distancing

themselves from the tragic individual cases, triggered by reorganization and system

failure, by showing that the "average" is good quality in health care. It is is also a sign of

moral decay health workers to begin thinking the same way (Nyborg, 1996, Wyller et al,

2013). Dissatisfaction is especially present among young doctors and female physicians

and their medical instructors have been in stressed work conditions (Nyborg, 1996).

Many students feel that they lack sufficient practical experience. Others claimed that

changes in the role of the physician are perhaps more important than work stress. Key

factors are the devaluation of the patriarchal image of the physician and a strengthened

patient influence, which implies self-conscious patients, well informed about their own

illness: “Patients are not so patients any more” as Professor Ole Berg stated in his

lectures (personal communication). Physicians have moved from a doctor´s role in which

26

the art of medicine was the ideal, to a working role, where effectiveness and organization

are given priority, because it is based on factors of political decisions. The classic

physician´s role can be combined with a well-organized modern health services system,

although it is not an easy task (Evensen, 1996). When time is limited, the consequences

become evident as contact with their patients is reduced. All the above can be reasonable

and reflect a reality. But does this picture reflect the entire situation as a road without

return and hope for a better future for the medical profession? Scandinavian health care

system is claimed to be the one that all other countries try to copy. However, one should

also take into consideration if something else is missing.

Leadership in medicine, as in other settings, should be based on values that provide

appropriate direction to the use of institutional power and authority. Leadership also

requires managerial competence, “power” as it is defined in social psychology, as “social

influence” and authority (Gabel, 2011), but also as we mentioned this in chapter 2. The

power and authority, when directed primarily by self-interest, Plato teaches, such power

and authority may be corrupt and dangerous to the good of the Mann (Chervenak and

McCullough, 2001). Chervenakmay be and McCullough, 2001, state: Stress also occurs

when the physician experiences reduction in recourses that can be shown to be consistent

with fulfilling the fiduciary obligations of the patient. Physician-leaders should routinely

ask their subordinates, “What can I do to help?”

Essential to integrity is open and honest communication with subordinates and

accountability for management decisions. Part of open communication is accessibility

(for example, not using subordinate administrators or staff to buffer or block access).

27

Vices, which physician leaders should avoid in the clinical setting, are the psychological

harm of women who have experienced romantic or sexual overtures or contact from their

doctors. For the physician-leader, negative bias may be based on race or illegal forms of

discrimination in hiring or promotion on the basis of gender or personal relationship.

When institutions merge, vice can take the form of favouring departments or individuals

without an objective evaluation and with physician-leaders in managed care preferentially

contracting work to friends, or former associates. In the clinical setting, self-sacrifice is

violated when clinical physicians-investigators use the “thumb screw of persuasion” to

put undue pressure on their own patients to enrol in their own clinical trials. The

academic physician- leader violates self-sacrifice when, as a chairman or division chief,

insists on being an author on every paper coming from the department. The managed care

physician-leader contributes to a morally corrupt organizational culture when threatens

and at worst undermines the culture of professionalism and, therefore, relationships with

colleagues. The physician-leader, who seeks productivity improvement by demanding

that everyone does more with less professional and personal impact on subordinates,

lacks compassion and risks creating a work environment that is exploitative and even

inhumane.

Doctors convey a mixture of hopelessness, frustration, and anger mostly because of

government mandated budget cuts with attendant staff. These reductions together maybe

with the likelihood of poor morale of those who remain, may help to a failure in the good

function of health organizations (Gabel, 2011).

The key question may perhaps be the following: How can major virtues be implemented

in a culture that says, “Protection of the organization´s economic interests is our primary

28

goal?” Leaders in the 18th century in Great Britain faced the same crisis we are facing

now. Should we practice medicine as a business through which we make a living, or

should we practice medicine as a profession through which we best serve our patients? If

the latter is the answer, is this a winnable battle? “self-sacrifices need to be balanced

against legitimate self-interest”. To clinical ethics, principles are prima facie, so are the

professional virtues.

A study of 314 professional managers found that it was individual managers and not the

organization that determined the organization´s ethical direction. Managers, therefore,

require a moral strategy that incorporates ethical virtues, such as excellence and

inspiration (Carney, 2006). Research findings from questions requiring qualitative

responses showed that healthcare clinicians and non-clinicians demonstrated a range of

values in the delivery of health care, some of which have not been identified before.

Clinicians perceived that non-clinicians did not hold the same ethical values and beliefs

as they did, and vice-versa, demonstrating a lack of trust in each other´s moral and ethical

value system. Health care managers need to develop “adequate moral strategy”, and

hence there is an urgent need for such leaders to formulate managerial moral principle

and ethics. Professor Ole Berg mentioned this in his lectures too, when he was referring

to politicians in general. In addition, to the lack of trust between clinicians and non-

clinicians relating to each other´s moral and ethical beliefs, not all values and beliefs held

by these two groups are ethical. The organizational culture influences ethical care

delivery substantialy (Carney, 2006). The authors end with the question: should

professionals now consider the ethical values required in the delivery of health care?

29

One may, therefore, be certain that we face a crisis in the organizational culture and

professional virtues. How important will it be to apply balanced Hippocratic and

Christian ethics, in modern Health Care Institutions? That will definitely promote health

care by giving administrators and health-leaders the tools to win the battle of crisis. “To

be fully successful, arguments must be such as to change the heart” (Solbakk, 2004).

Sometimes, therefore, we have to permit our intelligence, instinct and heart to guide us

together with knowledge.

Chapter Two: Methods in a historical view

Methods

The method we used in this thesis was a brief, documentary, exploration of some of the

literature dealing with issues of medical ethics from a historical perspective, from

Hippocratic times, to early Christian times and up to the modern times of secular

medicine. There are enormous numbers of articles focusing on medical ethical issues in

general. We have tried to focus selectively on these articles as we will see them influence

development and rapid growth of medicine on Hippocratic ethics, from his days to

modern times. With this development into the secular society crises of values emerged,

possibly due to the fact that society distanced itself from God and modern people from

each other.

At stake is the status of man as a prosopon and anthropos (Hierotheos, 1999). In our

technocratic society of a frenetic and stressful life, with its callous laws, the brutal

economic conciliation and the moral barriers, the concept of humanism is sadly sidelined

30

in the hearts and minds of modern people. We have demolished love for beauty, truth,

justice, and righteousness. Likewise, we have also lost respect for ourselves, and love for

our neighbour. In this respect we have focused partly on original literature from

Hippocrates and the Bible and not as much on medical ethics such ethics may only refer

to the great results of developmental biology. Today modern hospitals have lost their

compassion. The applied medicine of today is oriented towards efficient production.

Furthermore, biomedical technology has contributed little to the fields of human ethical

problems. All of these factors along with a range of other characteristics in the behavior

of society such as acceptance appreciation, and admiration of the clients involved in the

research process, has sometimes resulted even in doctors fabricating data, becoming

arrogant and thinking they are equal to God.

Modern and prestigious technology was previously associated with religion, as expressed

in majestic church architecture. During the 20th century, health had gradually found a

central place in the society, as medical technology and prestige have replaced the

previous standing of the church (Lærum, 1996). In the field of genetics and in the case of

cloning, the great results they have produced created an ethical dilemma. In this case the

results of putting together live cells, especially those of human beings, can be seen in

different ways. A theologian may moralize and an ”atheist” may theologize. It seems that

ancient medical etiquette and Hippocratic ethical concept which is based on the co-

existence of both Asclepian Art, which relied on religious faith and the rational

Hippocratic medicine renders science insufficiently. In this respect, therefore, we would

like to focus only partly on relevant medical literature, focusing more overall on ethics in

respect of a culture based on humanistic values, and do so from a historical point of view.

31

Chapter Three: The beginning. Hippocratic Medical Ethics

1. The introduction and continuation of Medical Ethics

Hippocrates was born on the Greek island of Kos around 460 B.C. He was determined to

reform medicine, to give it a new character based on a particular concept of God (Gods in

his time) and of human dignity. Hippocrates was of course neither a Christian nor a Jew.

Medical historian Ludwig Edelstein points out that he, however, had a fundamental

conviction, common with both: The belief that one supreme God exists (Henotheism) and

that we human beings, male and female, are made in His image. This is forgotten in

modern medicine (Brown, 1998). The Hippocratic Oath forms the classical basis of

medical ethics. To understand its significance, it is important to know that an oath in

antiquity involved a sacred obligation and responsibility. Unfortunately, we, today, to a

greater extent have a weak concept of both. The Hippocratic oath, (see modern

translation appendix 1), teaches the importance of responsibility in diagnosing patients

and emphasizes professional dignity. In addition, it represents a promise and obligation

to the patient, to secure their health as the first priority. Medical ethics deal with right and

wrong in the behavior of physicians during their professional lives. It is obvious that

medicine without ethics is a potentially dangerous profession. Hippocrates (5th century

B.C.) was the first to teach a Rational Medicine based on accumulated knowledge,

separating Greek Medicine from the magic-religious priest medicine of the ancient times,

recognizing at the same time Godliness as the guiding principle of every practicing

Asclepiad (Mylonas and Tzerpos, 2006, Kaba, Sooriakumaran 2007). The Hippocratic

text symbolizes the ethos of Classical Greece and the ideals of philanthropy, honesty and

love for mankind. “For where there is love of man, there is also love of Medical art”

32

(Marketos, 2000, 2004) The Hippocratic oath, directly and indirectly, also includes

references to express respect for teacher, students, colleagues, but above all loyalty

toward the patient. The Hippocratic oath presents a promise to the patient to make their

health as the first priority, to protect their confidentiality, to refrain from performing

abortion and euthanasia, from having sexual relations with patients or their relatives and

to lead a professional life with ethical values, that fosters trust in the physician – patient

relationship and confidentiality, as it is written earlier (Marketos, 2000, 2004, Hjort,

2001).

Through the Hippocratic Oath, medicine becomes more than just a hard scientific

discipline. “I will keep pure and holy both my life and my art” said Hippocrates in his

Oath. It is important to remind physicians, us in general, that physicians’ first duty is to

their patients and NOT to their government or to the Health Maintenance Organization

they work for (Shuster, 1998). It will require also a widespread awakening of a spiritual

nature. Physicians of course should request more help than what the very memory of

Hippocrates alone can give them. Hippocrates, alone, cannot take us there, but he can

point the way (Brown, 1998), but it is evident that it should form the Ethical guide for

Medical practice even today. Hippocratic medicine is contemplative and non-

interventionist in nature. Hippocratic ethics continue to serve as a cornerstone of the

professional behaviour and will continue to be the "nucleus" of medical ethics. It might

also be relevant to underline that The European Declaration of human Rights, in 1950, as

well as the two UN conventions on human rights as early as 1966 include several issues

from the Hippocratic Oath. We find these issues also in the Declaration of Geneva

(1948), the Nuremberg Code (1968), the Declaration of Helsinki and its revision (October

33

2000), which includes almost half of the ethical precepts outlined in the Hippocratic

Oath, (Forster et al 2001, Carlson et al, 2004).

Hippocrates was respected not only as a greater physician and teacher, but also as an

inspired philosopher and thinker. He has elevated the Greek antiquity to the status of a

symbol, where both can be seen as a mixed blessing. “For where there is love for man,

there is also love of Medical Art”. The Hippocratic Oath is one of the oldest documents

in history and symbolizes the Ethos of Classical Greece and the ideals of philanthropy.

Hippocrates swears to all his Gods. The principles of the Hippocratic Oath (see modern

translation appendix 1) are held sacred by doctors, in their majority, up to our days. The

Hellenic pre-Christian tradition expressed by Hippocrates and other pre-Socratic

philosophers, should be regarded as a continuation with the Hellenic-Christian tradition,

where man is union of body, mind and soul, ie both matter and spirit. In other words, a

visible and invisible nature as the Creator, “moulted the body from the earth” and

“endowed it with the divine and lifegiving spirit”, as St. John the Damascene (Warwick

G.N) proclaims . The Hippocratic ethics and the Christian ethics express the same

“ethos”, the same vision, and have always been like this. Their values are derived exactly

from the same ethical principles. They are derived from love to help, to heal those in

need, to do them well and to avoid harming them.

Aristotle’s most important work in ethics include: human wellbeing, happiness

(eudaimonia) and virtue. And the Golden Mean of ethics is the “right amount” principle,

i.e. every feeling, desire, or activity should be at the right time, in the right way, to the

right degree (Aristotle, 384-322 BC) “ Παν µέτρον άριστον”. It is important to note that

the ascendance of Christianity did not diminish the stature of Hippocratic Medicine and

34

Asclepius cult for the worship of Christ, our God´s Son. The principles of the Hippocratic

Oath (see appendix 1), and God’s words spoken in Decalogue (Decalogue, Exodus,

chapter 20), see appendix II, are based on same values and principles.

2. Aristoteles´ virtue and Hippocratic Ethics

Aristotle’s with his influential works in a range of disciplines such as politics, physics,

ethics and economy, had a profound impact on Western thinking. Hippocrates´s and

Aristotle’s ethics were based on virtue “aretê”. Aristotle’s main concern in his treatise of

ethics, as mentioned earlier, was human wellbeing, happiness (eudaimonia) and virtue

(Greek aretê), involved in human´s life. In other words having excellent and well-chosen

habits. Character (êthos) (Marketos, 2000, Warwick, wikipedia). The original

Aristotelian and Socratic answer to the question of how best to live was to live the life of

philosophy and contemplation. With respect to good habits, it involves activity in

accordance to reason ”arete”.

Virtue ethics is currently one of three major approaches in normative ethics. It may

initially be identified as the one that emphasizes the virtues, or moral character, in

contrast to the approach, which emphasizes duties or rules (deontology) or that which

emphasizes the consequences of actions (consequentialism).

Hippocratic and Aristotelian ethics do not imply ethical relativism because there are

appropriate, relevant standards, as we will discuss later.

3. Ethics in theory is also a question of personal character (Greek approach)

Plato said: «Πάσα επιστήµη, χωριζόµενη δικαιοσύνης και άλλης αρετής, πανουργία, ου

σοφία φαίνεται», which means, “Any science separated from justice and other virtue

35

(aretê), seems cunning and not wisdom to me” (Marketos, 2000). Arête is the classical

Greek term for ”virtue” and is untranslatable. In tracing classical education and, so, virtue

through ancient history, Marrou suggests that virtue is the ideal value, to which life itself

must be sacrificed.” Arête was for the ancients more likely to be grasped in a person than

in a definition. Arête is best summed up as how one lived and died in the effort to

embody a certain ideal, a quality of existence” (Yannaras, 2002).

Everybody in our days, no matter if he is a young or a mature adult, and no matter

whether he is a doctor, biologist, theologian, lawyer, historian, archeologist, sociologist,

economist, or other, would not disagree with the leader of the Chorus of Sophocles’

Antigone that “of all miracles of the world there is nothing more marvelous and greater

creation than the human being”, “the anthropos” (Sophocles, Constantelos) The ancient

Greeks regarded man as a “fallen god”, because he dared to make himself equal in power

with the divine. But Homer counseled: “Do not desire to imagine yourself similar and

equal in power to the Gods” (Constantelos).

In no historic period of ancient Greece, man was regarded only as a body, but rather an

eternal spirit or soul and a corruptible body. Thales of Miletus, Heraclitus, Socrates, Plato

and many other ancient Greek philosophers regarded the souls as little Gods. For

Heraclitus, the soul is not explorable and spreads to the infinite (Heraclitus, 119 in Kirk

and Rowan 1975). It is the soul–daemon-good spirit, which distinguishes man from the

rest of creation. “Ethos to man is the daemon”, says Heraclitus. Concerning the spiritual

nature of man, Socrates emphasizes that man pre-existed as a created species. He speaks

of discipline and creation of human ethos and recommends the need for flight from the

36

evil of the perceptible world, the pursuit of spiritual cultivation and the elevation of man

to the level of Gods.

Socrates obeyed the democratic decisions and behaved according to the laws of Athens at

the time he was judged to take the conium. Whether this was a right decision and

judgment of the Athenian State is another matter. But his character and behavior were

obviously influenced by his philosophical views, according to his ethics and belief. The

last words Socrates said were “Crito, we owe a rooster to Asklepios”. May be other

power could give another kind of blessing or an explanation to our actions and decisions.

Bonus intra. Melior exi (Come in good and Go out better) (Pederson Sandra).

Thus, ethics is supposed to promote a person´s good behavior and judgment and protect

against bad practice.

Character traits are all the aspects of a person’s behavior and attitudes that make up that

person’s personality. Everyone has character traits, both good and bad, strengths and

weaknesses. Character-based virtue ethics is ethics that deals with the right or wrong of

individual actions, it provides guidance as the sort of characteristics and behavior a good

person would seek to achieve. Virtue ethics is concerned with the whole of a person´s

life, rather than particular episodes or actions.

Important to remember is that moral attitudes and behavior are also shaped by the culture

and subculture we belong to, and such cultural differences play a big part in the divergent

moral judgments of a person in general, even to a health, managerial or political leader.

Moral criteria are influenced by our instincts too. What makes moral judgments so

37

compelling is the fact that because they are powered by positive emotions such as

compassion and by negative emotions such as contempt (Barondes, 2012). To make sense

of a person´s character strengths and weaknesses we have to consider how the person

measures up on the three domains of character: Self-directedness, cooperativeness, and

self-transcendence. We can then examine the way the person expresses each of the six

core virtues: temperance, courage, humanity, justice, wisdom, and transcendence

(Barondes, 2012).

Synonymous with the words individual, person and man, male or female, is the word

“prosopon” “person” in Christian orthodox sense. Is man a person or a mask? (Zizioulas,

2007). Is man a philanthropic or at times a misanthropic individual? Is his basic nature to

achieve power, and above all to dominate weaker men? The answers to these questions

depend upon several views and perspectives (historical, religious or theological,

biological, psychological, and economic). We will see briefly how the ethical thinking in

the western world of today has been influenced, from “religious” point of view by the

pre-Christian and post-Christian thinking.

Chapter Four:

The Hellenization of Hippocratic Medical Ethics

1. Hippocratic Medical Ethics in Hellenistic times.

The Greeks developed a system of medicine based on empirical- rational approach. This

system seemed to hold the first place among nations to evolve towards a democratic form

of social organization, and with the distinguishing patterns of the doctor – patient

38

relationship, which was based on Hippocratic medical ethics. The latter played an

important role in the philosophical thinking of the physicians and philosophers at that

time. The Hippocratic Oath raised medical ethics above the self-interests of the class and

status. They are still having great value today for the medical profession and for all

concerned with the ethics of medicine. They present the ideal for the selfless, dedicated

and compassionate doctor and they have lost none of its relevance in the twentieth

century (Kaba and Sooriakumaran, 2007 Lloyd, 1950, 1978, 1983). Certainly, in the

debate between reason and sensation, some of the philosophers argued that the reason

was to be preferred, but also tended positively to denigrate sensation. Aristotle goes out

to defend and support the practice of observation particularly in his biological works

(Lloyd, 1950, 1978, 1983).

Any dreams were reported to the priests who interpreted the divine intent and gave the

diagnosis and treatment. In thanks for their renewed health, people would frequently

leave on anatomically correct votive of their previously afflicted body parts. Around the

Hellenistic period, belief in Olympian Gods was declining. Asclepius’ cult was solid in

the 4th century BCE, and continued to be strong through the Hellenistic times and into

the early Christian times. He was the personification of the miracle-working physician of

consummate medical skill. (Cameron Caroll, 2012, Asclepius Wikipedia).

Alexander's conquest of the world resulted in Greek culture and Greek language to be

spread into various cities as Far East as Afghanistan and Pakistan. The fruitful union of

Greek and Near Eastern cultures faded during this Hellenistic age. Hellenistic kingdoms

were established and these were important because they united the culture of the Greeks

39

and the Near East, where common spoken language was the Koine Greek dialect. If you

wonder how Jews like the apostle Paul came to write the New Testament in or the

epistles in Greek it is because of the common Greek language of the Hellenistic

Kingdoms` (Kishlansky Mark, 2012, Epicurus, Epicurean history, Ελληνιστική

περίοδος, wikipedia, Warwick G.N,).

During the Hellenistic era, new philosophies developed and among them Epicurus from

Samos (341-271 BC) focused on how individuals might be as happy as possible in an

imperfect world. Epicurus founded one of the major philosophical Schools of ancient

Greece, a godless philosophy, helping to lay the intellectual foundations of modern

science and secular individualism. Epicureanism emerged in Athens with a rational

thinking, which combined physics with hedonistic ethics that emphasized moderation of

desires and cultivation of friendships (Kishlansky, 2012, Epicurus, Epicurean history,

Ελληνιστική περίοδος, wikipedia, Warwick G.N).

Two other great philosophical schools emerged in opposition to Epicureans, namely the

Stoics and the Skeptics. The debates among these Hellenistic schools spurred Epicureans

to develop some of their doctrines in much greater detail of their epistemology and some

of their ethical theories, especially their theories concerning friendship and virtue

(Epicurus, Epicurean history, Warwick G.N,).

After the death of Alexander the Great (323 B.C) and with the emergence of Rome as the

leading power in the western Mediterranean and after the defeat of Carthage in the

second Punic War (201 B.C.), Romans took a greater interest in Greek affairs and

ultimately in Greek culture. Greeks lost their political freedom - democracy is no longer

40

existent and war and politics are no longer the focus of most people's lives. Art becomes

more realistic; drama and philosophy emphasize individual happiness (Kishlansky, 2012,

Epicurus, Epicurean history, Ελληνιστική περίοδος, wikipedia, Warwick G.N).

A truly "Greco-Roman" culture was formed. Romans adopt Greek (Hellenistic) culture.

The Romans conquered the Greeks but the Greeks ended up influencing Roman culture

far more than Roman culture influenced Greek. Mainland Greece – especially Athens,

remained the center of drama and philosophy in the Union of Near Eastern and Greek

civilization (Kishlansky, 2012, Warwick G.N,).

Religions and medical views of disease in the ancient world were not mutually exclusive.

As mentioned earlier, physicians in ancient Greece were members of a religious cult as

much as they were physicians, but Hippocratic medicine did try to avoid supernatural

interpretations of illness, including mental illness. The empirical School trained doctors,

the dogmatic school, which was a continuation of the Hippocratic School and the

methodical school, which had a great success, were flourishing in Alexandria during the

Hellenistic period (Warwick G.N).

Galen was born in 131 A.D, in Pergamum, a Greek city on the Aegean coast of Asia

Minor. Pergamum was an ancient center of learning and medicine, having an Asclepeion

and a famous library, which was second only to the one in Alexandria. When Galen was

just a boy, his Greek father Nicon had a dream in which Asclepius appeared to him and

told him to let his son study medicine. And so, the young Galen went to the local

Asclepeion to be trained by its elder physician-priests. Galen remained a lifelong devotee

of Asclepius. He first studied in Smyrna, and then traveled to Alexandria, where he

41

finished his studies. His medical training in Alexandria made him an empiricist. Galen

was a master of medical philosophy, he believed in the Aristotelian doctrine and he

considered the study of philosophy to be essential to a physician's training. Galen

certainly admired other aspects of Hippocratic teaching but his enthusiastic endorsement

of the schematic of the Nature of Man was especially influential. After the second

century A.D., Galen himself rapidly became the chief authority on questions of anatomy,

physiology, and pathology, as well in philosophy, and mathematics. The Elements

according to Hippocrates and the opinion of Hippocrates and Plato (both of which are

extant), in the body of Galen’s writing, are directly or indirectly related to Hippocrates.

Galen held that Plato must have had the Nature of Man in mind when he made Socrates

attribute to “Hippocrates and the true account” a method that first considers whether a

thing is simple or complex. Galen still ranks first among “all the best doctors” as one who

follows the Hippocratic principles and opinions (Lloyd, 1950, 1978, 1983, Galen, Greek

Medicine). No doubt Galen brought Hippocratic Medicine into the West, whereas

Hippocrates laid the foundation of Greek Medicine. Galen further developed its theory

and practice, and carried Greco-Roman medicine to its zenith (Lloyd, 1950, 1978, 1983).

Chapter Five:

The Christianization of Hippocratic Medical Ethics

1. Christian Ethics

We will mention again the proclaims of John the Damascene (Warwick G.N). The

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Hippocratic ethics and the Christian ethics are aspect of the same “ethos”, the same

vision. Their values are derived exactly from the same ethical principles. They are

derived from the values of love to help, to heal those in need, to do well and to avoid

harm. Christian ethics refers to what is good and evil, right and wrong. Christian ethics

has its roots in the Old Testament. Christian ethics in biblical terms is tied to theology

because it is grounded in the character of God (Theos in Greek). Francis Schaeffer

explains the uniqueness of Christian ethics: “One of the distinctions of the Judeo-

Christian God is that not all things are the same to Him. He has a character; some things

conform to His character, and some are opposed to His character. The governing

principle of the Old Testament´s ethics was the character and nature of God, that the

Lord was holy (e.g. Lev. 19:2) (Peter 1:16). Holy means pure, is the loving nature of God

and is separate from evil. For Christianity the final criterion is the Truth. The Decalogue

includes obligations for individuals (see Appendix II). The Old Testament´s major

contribution to ethics includes: accountability to a monotheistic God, to live humbly,

righteously, and wisely. It also emphasized the social responsibilities without diminishing

individual accountability and responsibility. As earlier stated, New Testament´s ethics

include the Old Testament´s writings, but the most significant contribution is Jesus

Christ, Who presents principles for ethical behavior, giving us a model role with His life

and teaching 'Love the Lord your God with all your heart, soul and mind.' And 'Love

your neighbor as yourself.' All the Law and the Prophets hang on to these two

commandments (Matthew 22:37-40). Apostle Paul told to the Corinthians impressed by

people with supernatural acts: “If I have a faith that can move mountains, but have no

love, I am nothing” (1 Corinthians 13:2). To love your neighbor is also love for your God

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as Lord that created man.

It is advised to empty ourselves from self- confirmation, from our ontological self-

fullness and our self-admiration and self-glorification, which is not so easy to achieve.

This is what the Bible and the Fathers of the Church call self-love, selfish [philautia] (2

Timothy 3:2), apparent, and not apparent. Christian ethics presuppose the equality values

between people, where all human beings are equal in dignity, respect for all human

beings, human rights, work, property and savings, which was important for the stability,

as God´s words were spoken (Decalogue, Exodus, chapter 20) (See appendix 2).

These are principles of the dignity of the human person, which is the foundation of all

other principles and content of the Church´s social doctrine; the common good;

subsidiarity; and solidarity. These principles, express the whole truth about man known

by reason and faith, are born of the encounter of the Gospel message and of its demands,

and they are summarized in the supreme commandment of love of God and neighbor in

justice with the problems emanating from the life of society. (Pontifical Council for

justice and Peace, 2004). A society that wishes and intends to remain at the service of the

human beings at every level is a society that has the common good – the good of all

people and the whole person – as its primary goal. The human being cannot find

fulfilment in himself, that is, apart from the fact that he or she exists ”with” others and

”for” others. The common good involves all members of the society, must be served in its

fullness, it requires the constant ability and efford to seek the good of others, as though it

were one´s own good. (Pontifical Council for justice and Peace, 2004). The responsibility

for attaining the common good, besides falling to individual persons, also belongs to the

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State, since the common good is the reason that the political authority exists. To ensure

the common good, the government of each country has the specific duty to harmonize the

different sectoral interests with the requirements of justice. Common good of the society

is not an end in itself; it has value only in reference to attaining the ultimate ends of the

person and the universal common good of the whole of creation. Solidarity higlights the

intrinsic social nature of the human beings, the equality of all in dignity and rights and

the common path of individuals and peoples towards an ever more committed unity.

Solidarity is seen under two complementary aspects: that of a social principle and that of

moral virtue. Solidarity mast be seen above all in its value as a moral virtue that

determines the order of institutions. Solidarity is also an authentic moral virtue, not a

”feeling of vague compassion” or shallow distress at the misfortunes of so many people

both near and far. On the contrary, it is a firm and persevering determination to commit

oneself to the common good. Solidarity ranks high as a fundamental social virtue since it

places itself in the sphere of justice. It is a virtue directed parexcellence to the common

good, and is found in ”a commitment to the good of ones´s neighbour” with the

readiness, in the Gospel sense, to ”lose oneself” for the sake of the other instead of

exploiting him or her, and to ”serve him or her” instead of oppressing him or her for

one´s own advantage (cf. Mt 10:40-42, 20:25; Mk 10:42-45; Lk 22:25-27). Solidarity

unites men and social groups among themselves, the space given to human freedom for

common growth in which all share and in which all participate (Pontifical Council for

justice and Peace, 2004). Solidarity in life is the message of Jesus Christ indicated in the

life of Jesus of Nazareth, the New Man, who is one with humanity even to the point of

”death on the cross” (Phil 2:8). Indicating the measureless and transcendent love of God-

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with-us. In the light of faith, solidarity seeks to go beyond itself, to take on the specific

Christian dimension of total grace, forgiveness and reconciliation. One´s neighbour is

then not only a human being with his or her own rights, who shares a fundamental

equality with everyone else, but someone who becomes the living image of God the

Father, redeemed by the blood of Jesus Christ and placed under the permanent action of

the Holy Spirit.

2. Hippocratic Medical Ethics from early Christian times to pre – modern times.

Whatever we may think of the Asclepian cures, the testimonies evoke, the healing

qualities of the physician - god and the power of a personal bond with patients. These are

not traditions that should be forgotten. Study of the cult of Asclepius yields fascinating

insights into the experience of illness and disease in the antiquity (Kellie, 1999).

Although Galen wasn't a Christian, he was a monotheist. This enhanced the acceptance of

his medical theories and teachings by later generations of Muslim and Christian scholars

(Galen, Greek Medicine).

Hellenistic kingdoms were important as we mentioned above in chapter 4, because they

united the culture of the Greeks and the Near East. Important doctors dedicated to

patients within the Hippocratic Medicine and Medical Ethics were also important links to

bring forward the Hippocratic tradition to the next generation. Aretaeus of

Cappadocia, (flourished 2nd century A.D), was another Greek physician from

Cappadocia who practiced in Rome and Alexandria, led a revival of Hippocrates’

teachings, and is thought to have ranked second only to the father of medicine himself in

the application of keen observation and ethics to the art. After his death he was entirely

46

forgotten until 1554, when two of his manuscripts, On the Causes and Indications of

Acute and Chronic Diseases (4 vol.) and On the Treatment of Acute and Chronic

Diseases (4 vol.), both written in the Ionic Greek dialect, were discovered. (Aretaeus,

Encyclopedia Britannica).

In parallel with the transfer of power from Rome to Byzantium, which was named

Constantinople and Nova Roma, by Constantine the Great (306-337), there was a transfer

of the medical culture and hygiene too. Baths and hospitals were numerous, and social

medicine made its appearance. There were famous doctors, such as Paul of Aegina, in the

city of Byzantium, but these did nothing else but repeat what Galen had said (Constantine

I, Wikipedia, Lloyd, 1950, 1978, 1983). Constantine played an influential role in the

proclamation of the Edict of Milan, which decreed religious tolerance throughout the

empire. He called the First Council of Nicaea in 325 A.C., at which the Nicene Creed,

was professed by Christians (Constantine the Great, Wikipedia). His reputation flourished

during the lifetime of his children and centuries after his reign. The medieval church

upheld him as a paragon of virtue while secular rulers invoked him as a prototype, a point

of reference, and the symbol of imperial legitimacy and identity (Constantine the Great,

Wikipedia). Constantine the Great, as the first Christian emperor, was venerated as a saint

by Orthodox Christianity and Eastern Catholic Churches of the Byzantine rite.

Christianity arose in Cappadocia relatively late with no evidence of a Christian

community before the late second century AD. However, Christianity became dominant

during the fourth century due to the conversion of Constantine and because of the

Cappadocian fathers of the church.

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The concept of the Cult of Saints was particularly widespread in this period. The most

famous among the adjuvant saints were Saints Cosmas and Damian (Saints Cosmas and

Damian, Wikipedia): they were twin brothers, physicians and early Christian martyrs.

They practiced their profession in the seaport of Adana, then in the Roman province of

Syria and then the patrons of the Medici family as well. They were called anargyri

because they did not ask for fee. (Saints Cosmas and Damian, Wikipedia). There were

protecting saints for every organ and against all diseases.

Ambrose (340 - 397 AD) was among the first to claim that the Holy Bible fulfilled the

ideals of ancient Greek ethics. His work “Duties of the Clergy” was a recognized

systematic ethics among the early church. Ambrose adopted the classical Greek ethic of

moderation, while devotion was expressed by joining a monastery.

St. John Chrysostom and St. Augustine, in particular, refer to Christ as the Great

Physician, the healer of mankind. Some Fathers offered more specific theories about the

effect of the body on mind and soul. Gregory of Nyssa (335-394), was one of the

“Cappadocian Fathers”. His greatest achievement is his remarkably balanced synthesis of

Hellenic (Greek) and Christian traditions, in an age when both were represented by

vigorous and acute minds. Gregory was also one of the first Christian voices to say that

slavery, as an institution was inherently sinful. He believed that slavery, violated

mankind's inherent worth, and it was the nature of humanity to be free (encyclopedia

Britannica, Wikipedia, Warwick GN). His brother Basil the Great studied in

Constantinople, and Athens philosophy, medicine, ethics, theoretics, logic and dialectics,

astronomy, geometry and mathematics. He refers to views of the philosopher about the

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creation and sustenance of the world, but he assessses them creatively both as a

theologian and a scientist. Sometimes he accepts them, sometimes he comments on them

or he gives his own different interpretation (Vlachos, 2012, Warwick GN, ). St. Basil the

Great, St. John Chrysostom and St. Gregory the Theologian (The Three Hierarchs, three

holy men of God from the 4-5th centuries AD), were “Pillars of Faith” for their defense of

the Divinity of Jesus Christ and their faithful articulation of the doctrine of the Holy

Trinity, who preserved the Christian Faith for use today. Basil the great, a man of great

virtue and love for the poor, built and organized some of the first hospitals and

orphanages. He defended both the deity of Christ and the Holy Spirit in the face of great

political pressures during a most turbulent time in Church history. These three holy

hierarchs were great examples of love for God and for neighbor, yet without

compromising truth.

After the division of Roman Empire (395 AD), the decline in learning was much more

rapid and severe in the Roman West than the Greek East. In the East as we have seen,

some knowledge of Galen and Hippocrates continued up till the seventh century and

beyond, but in the West scientific medicine sank to a low level. After the fall of

Alexandria in 642, knowledge of Greek medicine, as well as other aspects of Greek

learning spread through the Arab world (Lloyd, 1950, 1978, 1983).

The restoration of religious beliefs following the demise of Roman Empire, concluding in

the Crusades and witch burn throughout the middle ages resulted to the deterioration and

weakening of the doctor-patient relationship. The Old and New testaments were revived

49

and became widely accepted and the doctor, filled with power and in high-ranking

position in the society (Kaba, Sooriakumaran, 2007)

By middle of the 14th century, Galen had once again achieved the position of dominance

in the Greco-Roman world. Indeed in the 16th, 17th, and 18th centuries many leading

medical writers continued to express their admiration for Hippocrates (Lloyd, 1950,

1978, 1983).

After the fall of the Western Roman Empire in the 5th century, most works of the Greek

physicians were lost to Western Europe. In the 14th and 15th centuries, however,

Western Europeans began to rediscover Greek scientific and medical texts. This was due

in part to the discovery of Arab repositories of learning in Spain and elsewhere during the

Crusades as well as the immigration to Italy of Byzantine scholars after the fall of

Constantinople on 29 May 1453. The City of Saints, Emperors, and legends passed into

the Ottoman dynasty. Thus, began the years of Turkish rule until 1821. The Greek nation

survived after 400 years of occupation.

The period of the Turkish (Ottoman) occupation is a source of live examples of ethos and

excellence for the Greek Nation. Despite the known national disasters, the psychic pain

and humiliations, it was the incubation and starting point for a new model of social,

moral, and intellectual life. Education during those dark times contributed to the

preservation of our National traditions and ideals, the strengthening of religious faith and

the consolidation of National consciousness. Even as early as the 15th century, as well as

the 16th and the 17th centuries, we can see many attempts for National independence

supervised by the Church. The Greek Church was the "Arc of the enslaved Nation", as

50

the top Historian, Konstantinos Paparrigopoulos, says, carried the whole burden of

education that brought light and warmth to the enslaved Greeks who lived "in darkness

and under the shadow of death". It vitally and decisively contributed to the issue of

liberation. Therianos said: "...The Orthodox Church brought warmth to the Greek letters

in the midst of the most adverse and difficult times; it was the cradle and the savior in

days of misery and unhappiness" (Gallos, Apostoliki Diakonia).

This period of Ottoman occupation had a profound impact in Greek society, and among

other infuences there was also a migration of Greeks to other parts of Western Europe,

mostly Italy. This trend had also effect on the creation of the Greek diaspora that

influenced the advent of the rennaisaince.

Renaissance, encouraged through the emerging Protestantism, man´s search for

liberalism, equality, dignity, and empirical science. The Protestant protests against the

might of the Roman Catholic Church, the removal of English dominance from America,

and the momentous social struggle of the French revolution are marked illustrations of

dominant socio-political events. French revolution brought an end to en era in which the

mentally ill and socially underprivileged were incarcerated in dungeons (Kaba,

Sooriakumaran, 2007). During the 18th century, the symptom was the illness. During this

time, hospitals emerged as places to treat underprivileged patients. Doctors were few in

number, and the doctor-patient relationship was traditionally regarded as paternalistic and

passive. The patient now is hospitalized, medical knowledge has a rapid growth, and

doctor’s knowledge and skills in different disciplines are no longer focusing on

symptoms but on a more accurate diagnosis an insight, and exploration of patient´s body.

A new medicine was developed in a model according to which the patient became

51

dependent on results and seen as a result in doctor´s hands. The relationship between

doctor - patient in the new developed medicine was between a dominant doctor and a

passive patient. The Hippocratic doctor performs his medical art with Ethics according to

Hippocratic Oath which has become the core principle of Medical Ethics in the doctor –

patient relationship. Principles derived from the values of love to help, to heal those in

need, to do well, and to avoid harm. Christian ethics are aspect of the same “ethos”, the

same vision, like Hippocratic Ethics are (as stated earlier). But the relationship of doctor

– patient is rooted in meeting a personal God, which created the ethical concept. 'Love

your God with all your heart, soul and mind.' And 'Love your neighbor as yourself'

(Matthew 22:37-40). To love your neighbor is also love to your God as Lord created man

alike Him. “If I have a faith that can move mountains, but have not love, I am nothing” (1

Corinthians 13:2).

Chapter six: Modern Medical Ethics

1. Deontological medical ethics according to Kant

Deontology derives from the Greek word deontologia (deon- that means duty, obligation)

and –logia, which derives from the greek verb λέγω (lego – that means speak).

Deontological medical ethics is ethics according to Kant´s philosophy or thinking

(Immanuel Kant 1724-1804). Kant was a German philosopher. A leading 20th century

proponent of Kantianism was Professor Elizabeth Anscombe (1920-2001). Kant argues

firstly that to act in a morally right way, people must act from duty (deon). Second he

argues that it was not the consequences of actions that made them right or wrong, but the

motives of the person who carries out the action (Wikipedia). Kant' s ethics is founded on

his view of rational thinking as the ultimate good and his belief that all people are

52

fundamentally rational beings. This led to the most important part of Kant's ethics, the

formulation of the categorical imperative, which is the criterion for whether a maxim

(ground rule, principle of action) is good or bad.

Kant´ s ethics, being deontological, is revolving entirely around duty rather than emotions

and goals. It is fine if someone enjoys doing what he or she does, but it must be the case

that he/she would do it even if he/she did not enjoy it. The overall theme is that to be a

good person you must be good for goodness sake (Elisabeth Anscombe 1920-2001,

Wikipedia)

Under certain circumstances, obligations and duties expressed in norms of obligations

can be expressed in norms of rights. It is, thus, no more coincidence that the idea of

human rights emerged at the same time as Kant formulated his theory of deontological

ethics.

By anchoring ethics in rationally derived principles – that is, in something outside man –

deontology, as a modern ethics, broke with traditional ethics of virtue. It also broke with

Christian ethics, by secularizing the basis of ethics – that is, by basing it solely on human

rationality. By doing so it also took much of the emotional commitment out of the

practice of medicine. Just at this time, i.e. around the turn of the 18th century, the British

physician Thomas Percival formulated the first modern medical ethics, and thus also

spelled out what the new role of doctor had to be – namely that of a cool and rational

gentleman.

2. Utilitarianism

Utilitarianism is a theory of normative ethics holding that the proper course of action is

the one that maximizes an individual or collective actor´s utility, usually defined as that

53

actor´s happiness or reduction in suffering. The concept of utility (utilitarianism) is

established as a central part of economics. In economics utility is a representation of

preferences over some set of goods and services. Preferences have a (continuous) utility

representation so long as they are transitive, complete, and continuous (wikipedia,

Internett Encyclopedia Philosophy).

In a broader perspective the term utility includes several moral components. The

principal question is which of these components should be regarded as relevant within the

medical environment, and to what extent they should be regarded as relevant. It should

also be noted that utility is a flexible concept where several subjective components may

be included. It is also a concept that is subject to change.

Just like Kantian deontology utilitarianism in some sense places the source of morality

outside the hearts and minds of human beings, and in our case outside the hearts and

minds of physicians. They both represent “extrinsic” forms of ethics. But whereas

deontology places it in the “thin air” of philosophical (expert) rationality, and thinks that

some sort of ethical objectivity is possible, utilitarianism places it in everyone’s

subjective and “raw” feelings about the (possible) consequences of a course of action.

Utilitarians, like classical economists, did not (and do not) “weigh” preferences, but by

taking what they see as the strongest type of preferences, naturally based individual

egoism (often called individual utility), as their point of departure, they indirectly do so.

Thus, utilitarianism may seem to create an ethics that is even farther away from both

classical Greek and later Christian medical ethics, both more “intrinsic” forms of ethics,

than the more “objective” and more altruistic deontology. Utilitarianism does, however,

54

come in different versions, one more purely individualistic, and one more social. The

latter embraces to some degree altruism – e.g. by understanding gross inequality as a

public evil, i.e. something society ought to intervene against to reduce.

Modern medical ethics is primarily based on deontological ethics, but in the debates

about priority setting and rationing in recent health care policy-making, consequences are

given more and more weight: One is talking about the “utility” of different kinds of

medical interventions. In the debate about provoked abortion and end-of-life care

utilitarian concerns are also given growing weight.

Fundamentally this raises the question of what society do we want? The concept of utility

used as principal economic criterion in health care may come in conflict with the

objectives of Hippocratic and Christian ethics in the health environment.

Love should be rooted in the physician-patient relationship, as a part of human´s nature to

meet the God. It should not be underestimate that the Kingdom of God begins in the

people´s hearts and not only in people´s brain.

Chapter seven: The continued relevance of Hippocratic

Medical Ethics and Christian Ethics

The chronological evolution of the medical profession regarding ethical issues from

Hippocratic tradition of the ancient times to our Christian days of modern ethics have

been briefly described. Previously, patients were often considerably ignorant to

understand doctor’s thinking and to be involved in the decision-making process.

55

Consequently, informing patients about uncertainties and limitations was difficult.

Doctors would easily make decisions on behalf of their patients and applied their

knowledge, experience and medical ethics the way Hippocratic tradition used to do

before modern times. The physician´s dominant role was much appreciated for his

patients, and the society. There was no much distance between a patient and a doctor,

dealing in a trustful relationship. There was a relationship in which freedom was the

dominant instrument by which a doctor could realize his moral choices. St. Paul wrote in

his epistle to the Romans (8,21), one could give meaning to his inherent ability to make

free choices and acquire what is alled dignity (cf. Mt 10:40-42, 20:25; Mk 10:42-45; Lk

22:25-27). Dignity is the highest goal of existence and is acquired when a doctor makes

his choice in favor of the good for his patient or his neighbor. This is a relationship of

honest man, a doctor, who swears as Hippocrates, and evoked firstly the gods and

goddesses, to witness the oath taking. That is as a priest, a king in Christ, who rejects

“Philautia”, that lies in the kind of autonomy of the man. He succeeds because he simply,

as in the second part of the Oath, which is duties to the profession, with a long

acknowledgment of the gratitude of students´entering into the practice of medicine feel

towards their teachers, tries to establish a kingdom of heaven in earth, at least for his

patients. The third part of the Oath duties to the patients, which is separated into two

sections. In each of them the central tenet and the goal of medical practice is repeatedly

specified on the sentence “benefit to the sick”. “I will help the sick according to my

ability and judgment, but never with a view to injury and wrong-doing”. The expression I

will…. indicates that the Oath was to be taken by medical students or young physicians

before entering their medical careers. The highest positive statement and the main ethical

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principle for the physicians is centered in the two key-words: “Purity” and “Holiness”

(Marketos, 2004), trying to live in love by self-sacrificing and living according to Jesus´s

concern, namely not the salvation of man’s soul, but the establishment of the totality in

the man’s existence, in his entire habitat and culture (Lazarou, 2003). In each human

being has been given the possibility of acquiring experience of the union by Grace of the

created nature with uncreated energy of God in Jesus Christ (Hierotheos, 1999, Vlachos

Hierotheos, 2012). In the case of high-tech medicine, with achievements such as ”gene

cloning”, human mind can momentarily overestimate his achievements and confuse

himself and / or his clients/patients with existential options. The orthodox opinion that the

theologians can give, is to face such cases theologically as the Holy Fathers of the Church

did, refers Vlachos Hierotheos. St. Basil was not a theoretical secular scientist, but a great

theologian. St. Basil speaks in that case theologically. And he differentiates Christian

cosmology from any other kind of cosmology. In the Christian cosmology, first principle

is that there is a difference between the Creator and creation, between the uncreated God

and created nature. The second theological principle is that the world was created from

nothing. i.e. not from material that did exist. The third theological principle is that God

manages the world with his uncreated energies. He manages it personally. The fourth

principle by St Basil is that the world, creation, is not self-serving. It is created and

sustained by God. It is necessary for man to lift his mind from the visible, to the invisible,

from the creation to the Creator. The fifth theological principle is that we also should not

attach ourselves to this present life, but give all our attention to the age that is to come.

He accepts everything that is related to scientific matters, provided that it does not disturb

these principles. St. Basil indicates the way which should be followed today in relation to

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contemporary scientific matters (Vlachos Hierotheos, 2012). Even if a human being was

to be cloned, it will still be created, with a precise origin, corruptibility and freedom,

which will not necessarily function positively, but can also functions negatively, and will

have a biological end. It will also have an end to its very existence, but that does not

happen because God wants it to be immortal by grace. Within the church we talk about

another form of ”cloning”, which science cannot give to man. The incarnation of Christ,

means that the created, was united with the uncreated. This confusion has to do with

secularism, which is the loss of the true life of the church, the alienation of Church

members from the genuine Church spirit. Secularism is nothing else but the rejection of

the ecclesiastic ethos and the permeation of our life by the so called wordly spirit. That

means in an eonistic (from the Greek word eon, century) way of existence, in this

century, in this present world, “this century” against “the future centuries” (Ephesians

1:21). Within such secularization and excessive rationalization, ethics no longer puts man

at its center in order to serve him but rather seeks to rationally justify his passions and

vices. Secularistic ethics concecrates the rupture between man and God, the

desacralization of the world and moral autonomy, so that the securalize man tries to

replace the laws of God with his own laws.

Therefore, physicians with no secularist ethics, who centered in the two key-words:

“Purity” and “Holiness” (Marketos, 2004) and who are trying to live in love by self-

sacrificing and living according to Jesus´s concern (Lazarou, 2003), will always succeed

in his destination not only as a doctor but also as a human on earth. That is also a

Hippocratic concern, which we find in the in Hippocratic tradition as much as in

Christian ethics tradition. Is this possible today? The answer is yes, though difficult.

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Many of the precepts and proscriptions contained in Hippocratic Oath are still recognized

as relevant today. This can also be reflected in Christian ethics where always man has its

center. This anthropocentrism of Christian ethics originates from the Mystical Body of

Jesus Christ. He thereby became the perfect model for man in all times and spaces. This

is why the moral prescriptions of the Church cannot but concern the good of man and his

true happiness. Therefore, decisive for the overall understanding of Christian ethics is its

humanitarianism, representing a profound concern for the good of man and enabling the

road toward perfection (Florea, 2008). The core of Christian ethics and the supreme

center of reference in these ethics, is the Supreme Good, Who is the center of Christian

theological values, axiology (from the Greek word axia meaning value). Jesus Christ is

He Who leads man in morality, efficiency, and perfection. Christian ethics cultivates

virtue not as a hollow slogan that belongs to wooden (rigid) church language. Virtue is

the product of a process of perfection starting from the waters of Baptism, which is the

beginning of the ethical program of life. Christians are members of the Mystical Body of

Christ. They are in the Church in communion with their neighbours and with Christ who

is the sole Head of the Church helping each other on the long journey of their lives,

struggling to learn fully and completely to love God (Florea, 2008). Like in the

Hippocratic tradition, the physicians of ancient Greece were members of a religious body

(in communion and community) as much as they were physicians (see above), rather than

acting as secular individuals. Seen from this perspective, resurrection through union with

Christ is the ethical (moral) program of life for a Christian, even in the very bitter heart of

our “fallen” civilization (Florea, 2008). This is the opposite of what Monod, 1970 said,

“man at last knows that he is alone in the unfeeling immensity of the universe, out of

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which he emerged only by chance. Neither his destiny nor his duty has been written

down. The kingdom above or the darkness below: it is for him to choose”.

It is important as well to see the fourth part (Epilogue) of the Oath that closes by

decreeing the consequences on the physician who fails to live as promised (Marketos,

2004). The Oath is a one-page text about which hundreds of thousands of pages have

been written through the ages and it´s not a legal text with a limited life span. Therefore,

it cannot deal with the ethical issues raised by human experimentation and by the medical

ethics of technology applications. It is often quoted in a segmentary way misunderstood

as a unified whole by some revisionists (Marketos, 2004). Its beauty, simplicity and

validity are in expressing higher abstract humanistic aesthetics and ethical values and its

elevation that can be seen as a symbol and as a mixed blessing.

In recent days, with the enormous development of science and the economic, political,

and social changes, the distance between patients and doctors has increased. This is

different from the ancient Greek community times. It is clear that modern ethics, with its

individualistic understanding of our modern days, differ in part from the Christian and

ancient Greek ethics, where deontology has clearer connection to Christian ethics than

utilitarianism, as we have seen also in previous chapters. The Hippocratic ethics advice

the ancient Greek doctor community through the entire exercise, to serve the patient

because this is the right (deon) thing to do. In the Christian ethics physicians serve

patients because they are doing the right thing as they are serving indirectly the God and

gaining eternal life. In contrast to the ancient Greek community understanding, in the

individualistic understanding of modern times, the relationship between the doctor and

the patient became impersonal and in many ways remote, having little to do with the

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world of medical ethics of previous medical era. Patient – centered care has replaced the

one-sided, doctor – dominated relationship in which the doctor was responsible for the

decision - making process for both parties (Kaba, Sooriakumaran, 2007). Doctors must

accept responsibilities for both a technical expert and a supportive interpersonal role.

Respect and shared decision-making must replace patient´s passivity. This is good in

many ways but on the other hand the enormous development of science can make

patient´s decision difficult. Doctor´s uncertainties, limited ability to communicate

effectively, unresolved conflicts can lead to their and the patient´s demoralization,

(Gabel, 2011, Jacobsen et al, 2007). On the other hand, the tremendous cost of

technology and health care can raise suspicion about where the money has gone.

Physicians may experience stress, burnout, or loss of meaning in their work. They may

also, have experienced a threat to losing personal goals and values because of numerous

issues, such as inadequate budgets, poor cooperation, and reductions in services and staff

mistrust between colleagues and or their Institutions.

Science is relevant in order to promote democratic decision-making within the society,

but this is not in itself always democratic. The contemporary preoccupation with the need

for ‘public participation’ in scientific decision-making threatens to erode this distinction

and demoralize professionals.

We have seen some examples in the chapter 1.3 that underlie problems in professionalism

in physicians´ behavior caused by lack of values and character issues or because of self-

promotion. These are crucial elements for dysfunctions in health care institutions, which

now play a central role in medical care. Such physician-leaders corrupt themselves and

their organizations, by putting self-interest – in power, authority, income, or job security-

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ahead of their obligation to sustain a moral organizational culture of service to patients

(Chervenak, McCullough, 2000).

The moral foundations put forward by Aristotle and Kant differ to the extent that they are

derived from different dimensions of morality. The basis in the morality of human

behavior as we have seen above may be judged according to different lack of moral

values. The provision of excellent health care services we provide to our patient should

be followed by ethical values and values based on the behavior.

No rules for physicians can eliminate these types of conflicts, but they ought to be some

guidelines to offer help in order to solve them. As long as this help is not offered,

physicians will most likely always return to Hippocrates when they think the patient does

not take his best interest into account. Hippocrates is important to keep always in mind.

Moral principles are not something you can tear from its theoretical basis as a supplement

to an already existing traditional cod because it sounds politically correct. In that case

principles will be empty ideas (Engelskjøn, 1996). The criticism for Hippocrates and the

demand for incorporation of other types of principles according to modernization of

Medicine shows that Medicine has the need to combine more Hippocratic ideas than ever.

On the other hand technological progress tends to remove modern medicine from its

anthropocentric mission. In addition, as we have seen (chapter 6. 1, 2), Kantian ethics is

based on his philosophy where gradually becomes immoral and secular. The revised

Hippocratic tradition ethics, does not totally respect physician’s autonomy. The principle

of autonomy, which is expressed in the request that the physician is to respect basic

human rights and to look after the patient´ s interests and integrity is attacked.

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The attempted synthesis between Hippocratic principles, (based on love for the patient

and philosophy - Aristotle´s virtue), and principles with completely different value terms,

attempts result that they are just there in order to cover underlying conflicts. In any case

that is a fundamental change.

The constructed new ethos for modern rights schools appears as it was built by new

builders who tried to mix oil with water, and lacked philosophical knowledge and values.

Modern ethics, a kind of pure thinking of means, attacked traditional Christian values

throwing man into uncertainties, into a desecralized world. Man takes off mask after

mask, without being able to find the one that defines him best (Florea, 2008). The world

of today seems to turn itself away from principles, values and spirituality. Non-

spirituality is one of the dangerous characteristics of contemporary man´s ethics, creating

ways that embodies principles of love and life which no longer are supreme, but only

principles of economic efficiency. In other words it seems that we are facing a

transformation to another level of ethics of philosophical pragmatism, utilitarian ethics,

turning human interest away from the world of spirit.

In order to overcome ethical tension, education relating to the ethical and moral dilemmas

of costs vs quality and the cost of caring need to be addressed in a non-confrontational

manner. Learning pathways for healthcare professionals are required, so that the

expectations of all concerned in healthcare delivery are met (Carney, 2006).

The realistic message for tomorrow´s physicians must be “to go forward” together with

the perennial humanistic values and clinical messages, combining the recent advances of

biotechnology with Hippocratic rationalism and on an integrated humane approach

toward the patient (Katsambas, Marketos, 2007).

63

The Hippocratic doctor performed his medical art with ethics, rationalism and

philosophy, caring for the patient as a total individual on a whole human approach, i.e.

not only as a body but also as an eternal spirit or soul as we have seen earlier.

Rationalism together with principles derived from the values of love to help, to heal those

in need, to perform well, and to avoid harm. This should be valid at all times. Science and

religion can strengthen each other (Farese, 2005, Mylonas and Tzerpos, 2006, Kaba,

Sooriakumaran 2007). It is important not to forget that Hippocratic principles were

applied also for respect for colleagues, students, and teachers. Christian ethics are aspects

of the same ethos and vision. Love for God and love your neighbor as yourself. To love

your patient, your colleague and your neighbor is also love to God. Thus you don´t harm

your patients not either your colleagues. Therefore a call for the Hippocratic and

Christian paradigm, as a doctor community through the entire exercise, is needed. Our

actions as doctors at all times should be accompanied by Hippocratic and Christian ethics

in order to provide the expected results for patient, themselves and the Institutions.

Chapter eight: Renewing the relevance of Hippocratic Medical

Ethics and Christian Ethics - a political approach

Dignity is the highest goal of existence and is acquired when a doctor makes his choice

according to Hippocratic ethics. In order to realize this, a doctor should feel completely

free to make his free choices in favor of the good for his patient or his neighbor, as

Christian ethics would dictate. Free is one who can live without telling lies. Our society

depends not only on good organisations and infrastructures, but also good leaders and

64

good leadership. Consequently when we say we are or we need good doctors, our duties

should be performed correctly from a medical point of view and, equally important, with

honesty. Is this easy to do today? And how it can be done? We need to go back for a little

while and look at the physician´s roles. As we have seen they were divided into four

different types. To serve the sick, which is the central part of his objectives, to serve

society, to serve science, and to serve the physician himself or herself, in order to succeed

in his/her personal goals and self-promotion. Ethics and norms are required in all of a

physician´s roles. The physician has traditionally been trained to perform the first three

roles. When they are performing the last one, they are governing or managing those who

are performing the other three roles. Ole Berg, Professor and expert in political science

call this fourth function a meta-medical function. This last role, especially, has mostly

been regarded simply as continuation of the other three that require professional insight,

but not much genuine managerial training. Professor Berg, in 1996, correctly states that

this “self-image” of a doctor is reinforced by the society´s public image of the doctor as

the person who will care, and devote his or her self to the individual patients. This goes

back to history and here he comes with an historical example: In 1985 the Norwegian

government was dominated by legally trained officials, the professional Board of Health.

The legal profession, by far the most powerful, had a chief justice, prosecutors, and

police chiefs in addition to occupying most of the important administrative and political

posts. The clergy had its bishops and the army and navy its generals and admirals. The

doctors had nothing, except for three, and later four professors, compared to the other

professions. This was humiliating for the physician´s community of that time. This is an

example that can teach us to strive to be represented by our own leaders from our own

65

The method we used in this thesis was a brief, documentary, exploration of some of the

literature dealing with issues of medical ethics from a historical perspective, from

Hippocratic times, to early Christian times and up to the modern times of secular

medicine.

It is true that there is little in the training of a doctor that teaches him that he should

devote time getting special knowledge for a meta-medical career. Professor Ole Berg,

(1996), underlines that managerial functions appear to pose a threat to the most important

aspect of the physician´s most important characteristic, that of his autonomy. This is what

we have also seen in the example of the reformation of Hippocratic ethics and the

consequences this has had for the physician´s autonomy and the doctor – patient

relationship, as we have discussed in chapter six.

He emphasizes that if medicine is to remain autonomous, it should be governed from

within. Representatives of the profession must govern it. Public medical administration

must be a continuation of the clinic into the bureaucracy, rather than other way around.

Public medical authorities must be organized as an “iatocracy” – a medical regime (Berg,

1996). He states that the rise of meta-medicine deals with the growing autonomy of

medicine, and that medical management is an extension of the clinical role. The fall is

about society’s “revenge” and about the normalization of health care as service

occupation. None, would contend could manage medical institutions better than a

dedicated doctor who performs his leadership with ethical consciousness, the relevant

medical knowledge, and experience in the leadership of health care institutions. History

has taught us that an ethically informed medicine has turned out to be crucial for patients,

from Hippocratic times to our modern times, with Christianity as a decisive mediating

66

force. It struck me therefore, when I recently was in the administrative building of the

University of Athens, School of Medicine, in the central meeting room, how appropriate

it was that a magnificent picture of “Theology and Medicine” had been hung beside an

equally magnificent picture of Hippocrates (see picture 1). It was exactly the story I

planned to support in this thesis, some years ago when I first started to think about

writing about medicine and ethics. Medicine and theology (religion) should continue go

side by side as it has from Hippocratic times to our days. Hippocratic ethics together with

Christian ethics must be the sources where physicians find the ethical values they need to

help their patients, society, and themselves.

Man’s place in the universe has to refer to the values of universal ethical principles. That

health, illness, death, and medical care are seen in a holistic perspective is extremely

important. Medicine cares about patients and religion about man´s life, including

mankind as a whole (body, soul and spirit). These thoughts and ethical issues bring

doctors, priests, and spiritual leaders to work together and very close to each other to

clearly affirm and help man in his everyday living in fulfilling the goals towards which

he was created.

67

Summary and Concluding remarks

Hippocratic ethics have dominated medical profession since Antiquity.

Hippocratic ethics are based on Aristotle’s most important moral foundation “aretê” and

love to patient and medical art, reflected in this Oath and its compatibility with

Christianity and Christian ethics as both are based on principles of the same ethos.

Hippocratic medicine´s first concern was and still is to put the patient first. This is also

the aim of the modern medicine today.

Utilitarian ethics dominate modern medicine today. Utilitarian ethics are different both

from Hippocratic and from Christian tradition, as they constitute an individualistic model

of understanding our modern times that dominates them.

“Health services face a crisis in Medicine and Health Care Institutions”, where turbulent

changes created by local and governmental policies, had an influential effect on moral,

philosophy and objectives of Medical world. These changes have affected the principle of

autonomy, which is expressed in request the freedom that the physician is to respect

patients´ rights and dignity. It is important therefore to understand who has defined the

goals in order to understand the outcome in every days practice. Christian and

Hippocratic ethics are much distanced from doctors today, but fortunately not in a

disappointed degree as we can see from literature. There is hope to win the battle of

crisis.

The future perspectives must therefore be directed towards the following aspects:

Doctors are forced to distance themselves from Ethics and norms, which are required in

all of physician´s roles and actions. Norwegian doctors of last century were Christians.

This implicitly claims doctors’ autonomy.

68

Doctors must regain their autonomy by getting involved in governing Medicine, and

Health Care Institutions on every level (from primary care up to the top governmental

posts) from within. Representatives of the profession who will govern must in at all their

action do this as Hippocrates and Christ thought us with their examples. These kind of

values must be applied not only in Health services but everywhere because crisis is not

only in Health care but everywhere and in medical environment as we have seen in recent

years with the economic crisis worldwide. No doubt that the Economic crisis we

experience nowadays is crisis of Values. This was referred to in “Aftenposten”

Norwegian newspaper, in an article written by Prof. Nina Walentyna Maria Witoszekn,

UiO in year 2006 and in several other articles afterwards. The important question is:

Should professionals now consider the values required in the delivery of health care, in

spite the obstacles from above? Ethical values and beliefs are demonstrated to be

fundamental for the mutual existence of trust in each other´s behavioral and ethical

system in order to serve the patient and themselves. This regards every one, young and

senior colleagues among themselves and within the institutions, and between citizens and

state alike. The state and the institutions ultimate destination is to serve their citizens and

vice versa.

Hippocratic humanistic values and the Greek civilization were spread all over the world

in ancient times and they are still present today. Economic crisis is crisis of values. Greek

economic crisis is also European and world crisis as The Greek civilization was spread all

over the world in ancient times.

69

Medicine of Hippocratic tradition and Theology is more than ever needed in Modern

times as the development of Modern Medicine has been and it will become even more

giant and almost uncontrolled in its dimension. Medicine and Health Care Institution´s

leaders have to provide their services with Hippocratic and Christian ethics for help of

their patients, their Health Institutions, and themselves. Physicians have a difficult task in

Balancing Ethical Issues, Knowledge and Experience in leadership, and it is possible to

succeed in their efforts if in addition they become conscious with the fact that the rise of

meta-Medicine deals with the growing autonomy of Medicine, and that medical

management is an extension of their clinical role, which is advised to be practiced with

Hippocratic and Christian paradigm, as a doctor community through the entire exercise.

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Appendix 1: The Hippocratic Oath (modern translation) The Hippocratic Oath -- Classical Version I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfil according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else. I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art. I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work. Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves. What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about. If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot. Translation from the Greek by Ludwig Edelstein. From The Hippocratic Oath: Text, Translation, and Interpretation, by Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943.

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Appendix II: Decalogue, Exodus, chapter 20 Decalogue, Ten Commandments

Ten Commandments by Orthodox religion/denomination http://en.wikipedia.org/wiki/Ten_Commandments#Text_of_the_Ten_Commandments I am the Lord your God. You shall have no other gods before me. You shall not make for yourself an idol You shall not make wrongful use of the name of your God Remember the Sabbath and keep it holy Honor your father and mother You shall not murder You shall not commit adultery You shall not steal You shall not bear false witness against your neighbour You shall not covet your neighbour’s wife. You shall not covet anything that belongs to your neighbour

Moses with the Ten Commandments by Rembrandt (1659)

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1. Tell everyone

Now, today, I shall sing beautifully for

my friends’ pleasure

2. We shall enjoy it

As for him who finds fault, may silliness

and sorrow take him!

SAPPHO* 612 B.C. (From Eresos, Mytilini, Lesvos, Hellas)

New translation by Mary Barnard

University of California Press, 1958 California, USA.

*Sapho was regarded the greatest female poet and the 10th muse of the antiquity. She wrote lyrics unsurpassed for depth of feeling, passion and grace and had a role as priestess and pedagogue (The Cambridge Engyclopedia, David Crystal, Guild Publishing, 1990, London, UK, Hele Norges Leksikon, Libri Arte Hjemmets Bokforlag A/S, 1996, Viborg, Danmark).